CLD stigmata checklist

Deeply focus on points in bold.

Stigmata of chronic liver disease - Bootcamp

WIPPER and the intro

• Introduce yourself and shake hands
• Washing of hands and appropriate hand hygiene
• Asking for permission
• Ensuring the room’s privacy
• Ensuring the environmental warmth and good lighting conditions
• Asking for appropriate exposure (from the xiphisternum to the symphysis pubis) (nipples to mid thigh originally)
• Asking the patient to be in the appropriate position (flat with \(1\) or \(2\) pillows ~ around \(10-15\) degrees)
• Relocating to the right side of the patient
• Asking for a chaperon
• “I have all of my equipment’s”

General look of the patient

• Consciousness, alertness and orientation of the patient to time, place and person (After asking the \(3\) questions)
• Comment on the patient’s position and comfort
• Comment on the patient’s external devices status, such as ~ stomas, drains, catheters, etc
• Patient is not in respiratory distress, not tachycardic, if he’s cachectic or obese

Vital signs

• Make sure you know the \(6\) vital signs
• Take height and weight to calculate BMI and assess nutritional status

Hands

Starting with a quick glance at the nails:

• No finger clubbing
• No koilonychia (IDA), leukonychia (Hypoalbuminemia)

[Mention Terry’s Nails, type of apparent leukonychia, characterized by ground glass opacification of nearly the entire nail]

Terry’s Nails

Moving to the still-hand examination:

• No dupuytren’s contracture (Alcohol-related CLD)
• No muscle wasting
• No palmar erythema
• No Hypertrophic osteoarthropathy (clubbing + periostitis of hand joints)
• No marks of I.V drug abuse

Palpation + tests:

• Palpate temperature and dryness/sweatiness (bilaterally)
• Test for flapping tremor (Asterixis) (don’t apply resistance!)

Face

Eyes

• Retract upper eyelid → no jaundice
• Examine conjunctiva → no pallor

Cheeks & Lips

• No sialadenitis/sialadenosis (parotid swelling; chronic alcohol abuse)
• No spider nevi (better mentioned on chest)

Mouth

• No halitosis (Fetor hepaticus)

Neck

• Mention examining the JVP (will be skipped)
• Mention examining the cervical lymph nodes (will be skipped)

Chest

• Normal hair distribution (no hair loss)
• No scratch marks
• No spider nevi
• No gynecomastia (male) / breast atrophy (female)

Abdominal Exam

Inspection – Foot of the Bed

• Contour (flat, protuberant, scaphoid)
  In CLD → distended abdomen due to ascites

Inspection – Right Side

• No distended veins (Caput medusae)
• No bruising

Palpation & Percussion

Tips:

• Palpate and percuss organs systematically with respiration.
• Normal liver span: 6–12 cm.
• Spleen → percuss ribs 9–11 (normally dull, non-ballottable).

Liver – Palpation

• Start at RIF, move 1 cm at a time with inspiration/expiration.
• If found → comment (smooth, sharp, non-tender edge).
  
• If not found → percuss upwards.

Liver – Percussion

• Ask for breath hold (after full expiration).
• During expiration, percuss down from the 2nd intercostal space to the point of dullness.
• Measure span (6–12 cm normal, no hepatomegaly).

Spleen – Palpation

• Start from RIF diagonally, normally impalpable.
• Roll patient and palpate again from umbilicus.
• Impalpable spleen; no spleenomegaly.

Spleen – Percussion

• Percuss ribs 9–11 → normal dullness.

Ascites Assessment

Three tests:

1. Shifting dullness
   • Percuss midline → flank dullness
     
   • Roll patient (wait 15s) → no shifting dullness
2. Fluid thrill
   • Hand on midline, flick other side
     
   • No transmitted thrill
3. Succussional splash (mention only)

Auscultation

• Auscultate over liver, spleen
  
• No friction rub

Ending the Station

• Examine external genitalia (atrophy)
  
• Examine PR (anorectal varices)
  
• Examine lower limb for edema, hair loss
  
• Check sacral edema

Hepatic Encephalopathy

We assess grade using West Haven Criteria:

West Haven Hepatic Encephalopathy Grading

THE END